depression and diabetes and... · 2014-05-20 · diabetes and depression • studies suggest that...
TRANSCRIPT
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Anne Finigan, RN MScN Team Lead – Diabetes Program
London InterCommunity Health Centre
May 15, 2014
Depression and Diabetes
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Depression
Anxiety Stress
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What is Depression?
• Depression more than just ‘feeling blue’ • Clinical depression is a severe and
potentially debilitating condition • Impacts every facet of life • Creates feelings of hopelessness,
helplessness, and/or worthlessness
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Is it an expectation?
– “Your children just left home- what do you expect?” – “Look everything you’ve been through! You should be
depressed.” – “ Your break up has been so stressful. Why wouldn’t
you be depressed?” – “Your marriage has just ended after twenty-five years.
Of course you’re depressed. – “ You had a heart attack. My God I would be
depressed too!”
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Is it a normal reaction to everyday stressors?
– “Roll with this. This is all just part of the
change.” – “In a few weeks from now, you won’t even
remember feeling like this.” – “Just be positive- it will go away in time.”
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Is it a personal deficit?
– “I think the whole family is nuts!” – “I should be able to cope.” – “ I just need to pull up my socks.”
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Depression is an illness
– Highly treatable – ~80% of people faced with depression
experience rapid improvement in 6 months if treated
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Depression
• Depression is a chronic disease with known tendencies to relapse.
1999 Canadian network for Mood and Anxiety Treatments (CANMET) pg. 51
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Risk of Recurrence
• After 1st depressive episode = 50% • After 2nd depressive episode = 70% • After 3rd depressive episode = 90%
chance of a 4th
CANMET 2006
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Prevalence of Depression • 1 in 20 adults in Canada at any given time are
affected by Depression • Male: Female= 1:2 • Age of onset: younger (mean 25-35 yrs) • Incidence: increasing • 3 times as likely in the unemployed **Life Time prevalence – 15%**
Murphy JM et al. Atch gen Psych. 2000; 57:209-12
Bland RC, et al. Acta Psychitry Scand Suppl. 1988; 338:24-42 Parikh SV, et al. J Affect Disord. 1996; 38: 57-65
Garfinel P. Centre for Addiction and Mental Health, 2002
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Depression Is…
• Imbalance of brain chemicals called neurotransmitters and a host of other factors that make people more or less susceptible
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Neurophysiology of Depression
• Common conceptualization of depression as a disorder of serotonin and/or nor epinephrine
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Pathophysiology of Depression
Nestler, E.J., Neuron 2002
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It is possible to envision depression as the result of over activity in some regions of the brain and under activity in other regions
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Causes of Low Mood and Depression Situations
Loss
Isolation
Conflict
Stress Actions
Social withdrawal
Reduced activity level
Poor self-care
Physical State
Altered sleep
Low energy/fatigue
Agitation
Changes in brain chemistry
Emotions
Discouragement
Sadness
Irritability/anger
Numbness
Anxiety
Thoughts
Negative thinking habits
Harsh self-criticism
Unfair & unrealistic thoughts
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Genetics
Depression
Psychological makeup
Negative thinking patterns
Physical illness
Excessive ETOH use
Difficult life events including major losses, abuse, poverty, immigration
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Etiology of Depression
Biological
Social Psychological
*Complex nature draws on skills of inter professional team
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Diabetes and Depression • Studies suggest that depression is twice as
prevalent in adults with diabetes than in those without diabetes (Eaton, 2002; Daly, Trivedi, Raskin, & Grannemann, 2007).
• However, Harris (2003) notes that depression may actually be three times more prevalent in the diabetic population when compared with nondiabetic individuals.
• While Barnard, Skinner & Pevelar (2006) identify that the prevalence of depression in people with diabetes is four times more than those without diabetes.
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Depression and Diabetes
• The co-morbidity of depression in the lives of people with diabetes can lead to compromised diabetes self-care (Lloyd & Brown, 2002; Lustamn and Clouse, 2005).
• Those with diabetes and depression at a greater risk of developing diabetes complications (Lustman & Clouse, 2002; Rubin, Ciewchanowski, Egade, Lin, Lustamn, & 2004).
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Which Came First?
or
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• Evidence strongly suggests that depression and type 2 diabetes are associated, but direction remains unclear (Knol, Twisk, Beekman, Heine, Snoek, & Pouwer, 2006; Donie, 2004; Eaton, 2002).
• Depression may occur as a consequence of having diabetes, but may also be a risk factor for the onset of diabetes.
• Adults with depression have a 37% increased risk of developing type 2 diabetes (Knol, Twisk, Beekman, Heine, Snoek, & Pouwer, 2006).
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The connection? • Loss of control • Life changing condition • Affects many life facets • Has potentially serious complications and health
consequences • Lack of supports to cope • Increase in stress • Altered body image • Decreased self-esteem
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Diabetes and Depression
• Despite high prevalence and impact on diabetes management, depression is recognized and treated in fewer than 25% of depressed diabetic patients
• Screen, Screen, Screen for depression
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What is Our Role? • Early diagnosis • Health teaching • Motivational Interviewing • Mental health support • Connection to community resources • Assess for depressive symptoms (such as lack
of energy, down affect, suicidal thoughts etc.) • Providing an opportunity for the person to
discuss how they feel this is impacting their life
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Psychological Impact of a Diabetes Diagnosis
• Guilt/Blame/Shame • Loss of Control • Denial/Avoidance • Loss of hope • Feelings of powerlessness • Altered Body Image/Role
Function/Personal Identity • Increase in Stress • Fear of unknown/Perceptions of
being a diabetic Dawn, 2001
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Depression and Chronic Illness
• The greater the disease severity,
increases the greater the prevalence of depression
(Swenson, Rose, Vittinghoff, Schillinger, 2008;
Phillips, 2000).
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Reaction to Diagnosis
• Diabetes-related distress is high at diagnosis (85.2% reported feeling shocked, guilty, angry, anxious, depressed, or helpless)
Soren E. Skovlund, Mark Peyrot on behalf of the DAWN International
Advisory Panel, The Diabetes Attitudes, Wishes, and Needs (DAWN) Program: A New Approach to Improving Outcomes of Diabetes Care, Diabetes Spectrum 2005, Volume 18: 136-142.
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Red Flags Identifying an “At-Risk” Pattern
• Don’t come to appointments
• Don’t bring their meter with them
• Don’t appear engaged • Don’t follow through on
actions • Chronically poor metabolic
control
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Focused Assessment of a “Red Flag” Pattern
Self Care Resources – Food security – Housing security – Social supports – Drug Plan
Self Care Capacity – Energy level – Cognitive capacity – Competing stressors
(score out of 10) – Sleep – Vision – Motor
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Depression is a common factor limiting Self Care
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Classic Features in Depression
• Low energy • Flat affect • Disturbed
sleeping • Disturbed
appetite • Low mood • Hopelessness
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Screening for Depression
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Key message
Depression is a highly treatable and the depression will improve significantly
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• The CBT therapist works together with the client on both negative thought patterns and behaviours that maintain the depression
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Interpersonal therapy (IPT)
• Focuses on different kinds of interpersonal problems that may cause problems for people with depression
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• Interpersonal conflicts may have caused the depression or might be the result of the depression
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• Four specific areas that are addressed with IPT
• Prolonged grief • Role transition • Interpersonal disputes • Interpersonal deficits
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• Goal of therapy is to build communication, dispute resolution skills, and help individual solve interpersonal problems in a structured way
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Medications
• For persons with a major depressive episode (MDD) medication is considered to be “first line” treatment
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• Many people with MDD say both medication and psychotherapy are of benefit
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• 20 different antidepressant medications currently available and they fall into “families” of medications
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• SSRI (selective serotonin reuptake inhibitor) – Example
– prozac or paxil – Most commonly prescribed medication for depression
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• Became available in the late 1980’s • Act by increasing the amount of serotonin
that remains available in the synaptic cleft
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• Other categories of antidepressants include Tricyclics, the MAO (monamine oxidase) inhibitors, Novel Action including SNRI’s
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• Augmentation Therapy – Becoming more available if no improvement
in 8 weeks
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Pearls • A little depression for a long time
devastates diabetic outcome • Use scaling based questions to break
through depression based all or nothing thinking
• Be careful to use measured optimism with the depressed person
• Treat depression aggressively – it is the LDL of mental health for the person living with diabetes
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The End